Chief Nursing Officer (CNO)

LANDMARK GENERAL HOSPITAL

JOB DESCRIPTION – CHIEF NURSING OFFICER (CNO)

• Position Title: Chief Nursing Officer (CNO)
• Department: Nursing Services
• Reports To: Chief Executive Officer (CEO) / Deputy Chief Executive Officer (DCEO)

4. Supervises

• Nursing Department Heads/ Head Nurses
• Staff Nurses and Midwives
• Supervisors
• Nursing Educators
• Other nursing personnel as assigned

5. Position Purpose

The Chief Nursing Officer is responsible for the overall leadership, management, coordination, supervision, and continuous improvement of nursing services at Landmark General Hospital. The CNO ensures that nursing care is safe, ethical, evidence-based, patient-centered, efficient, and compliant with applicable Ethiopian laws, professional requirements, hospital policies, WHO Patient Safety Friendly Hospital Framework (PSFHF) standards, and applicable hospital accreditation standards.

The CNO provides strategic nursing leadership and ensures that nursing services contribute to the hospital's quality, patient safety, accreditation, clinical governance, and continuous improvement objectives.

6. Key Duties and Responsibilities

Nursing Leadership and Governance

• Provide strategic and operational leadership for all nursing and midwifery services.
• Develop, implement, review, and monitor nursing policies, procedures, protocols, guidelines, and standards.
• Establish clear nursing reporting lines, accountability, delegation, and scope of practice.
• Conduct regular nursing management rounds and monitor nursing performance across all

clinical units.

• Ensure adequate nursing staffing, appropriate skill mix, duty schedules, and effective utilization of nursing resources.
• Participate in hospital executive management and multidisciplinary committees as required.
• Promote professional nursing practice, ethical conduct, accountability, teamwork, and effective communication.

B. WHO-PSFHF / Patient Safety Responsibilities

The CNO shall serve as a key nursing leader for implementation and monitoring of the WHO Patient Safety Friendly Hospital Framework (PSFHF).

Responsibilities include:

• 1. Ensure nursing services comply with applicable PSFHF requirements.
• 2. Promote a strong patient-safety culture throughout nursing services.
• 3. Ensure safe, evidence-based nursing practices are consistently implemented.
• 4. Monitor nursing compliance with patient identification, medication safety, infection prevention, falls prevention, pressure injury prevention, safe handover, documentation, and other patient-safety practices.
• Ensure nursing staff understand and follow patient-safety policies and procedures.
• Participate in identification, reporting, investigation, analysis, and prevention of adverse events, near misses, incidents, and sentinel events.
• Ensure nursing-related patient-safety indicators are monitored and improved.
• Participate in patient-safety and quality-improvement committees.
• Promote patient and family involvement in care and patient-safety improvement.
• Ensure nursing staff receive appropriate patient-safety education and continuing professional development.
• Maintain appropriate evidence and records demonstrating nursing compliance with PSFHF requirements. WHO's PSFHF specifically addresses leadership and management, patient and public involvement, safe evidence-based clinical practices, safe environments, and lifelong learning; these areas should therefore be reflected in the CNO's accountability.

C. Accreditation and Quality Improvement

The CNO shall be a key responsible person for ensuring nursing readiness for and compliance with hospital accreditation requirements. Responsibilities include:

• Ensure nursing services comply with applicable national and international accreditation standards adopted by Landmark General Hospital.
• Participate in hospital accreditation planning, implementation, internal assessment, corrective action, and follow-up activities.
• Coordinate with the Quality and Safety Department to identify nursing-related accreditation gaps.
• Develop and implement corrective and preventive action plans for identified nursing deficiencies.
• Ensure nursing departments maintain required accreditation documents, records, reports, checklists, indicators, and evidence.
• Prepare nursing departments for accreditation surveys and assessment visits.
• Participate in mock surveys, tracer activities, audits, interviews, and document reviews.
• Ensure findings from accreditation assessments are communicated to relevant nursing staff.
• Monitor implementation of accreditation corrective actions and report progress to hospital management.
• Promote continuous quality improvement rather than compliance only during accreditation periods.
• Ensure nursing quality indicators are regularly collected, analyzed, reported, and used for improvement.

D. Nursing Quality and Performance Monitoring

• Establish and monitor nursing quality indicators and key performance indicators.
• Monitor patient outcomes and nursing-sensitive indicators.
• Conduct or facilitate regular nursing audits.
• Review nursing documentation and patient-care records.
• Monitor compliance with nursing standards, protocols, and clinical guidelines.
• Identify trends, risks, and performance gaps and initiate improvement actions.
• Present nursing quality and performance reports to hospital management.
• Develop quality-improvement projects based on identified nursing and patient-safety

problems.

Nursing Management Rounds

• Establish a structured nursing management-round schedule.
• Conduct regular rounds with nursing heads and supervisors.

Assess:

• Patient safety
• Emergency preparedness
• Staff availability and attendance
• Nursing documentation
• Patient identification
• Medication administration practices
• Infection prevention and control
• Cleanliness and environmental safety
• Waste segregation
• Equipment availability
• Dressing-code compliance
• Instrument processing
• Patient satisfaction and complaints

Document findings and assign responsible persons and deadlines for corrective actions.

Follow up implementation of identified actions.

This is particularly relevant to Ethiopian hospital accreditation requirements, which include nursing management rounds led by nursing leadership and assessment of areas such as emergency preparedness, staff attendance, cleanliness, waste segregation, and instrument processing.

Infection Prevention and Control

• Ensure nursing compliance with infection prevention and control policies.
• Promote hand hygiene and appropriate PPE use.
• Monitor standard and transmission-based precautions.
• Collaborate with IPC staff on infection prevention activities.
• Ensure appropriate nursing practices for waste segregation, sharps disposal, isolation, sterilization/instrument processing, and environmental safety.
• Participate in healthcare-associated infection prevention and surveillance activities.

Staff Development and Competency

• Identify nursing training and competency-development needs.
• Develop annual nursing education and training plans.
• Ensure orientation and competency assessment for newly hired nurses.
• Promote continuing professional development.
• Ensure nurses maintain valid professional licenses and required credentials.
• Support competency assessment, clinical supervision, mentorship, and coaching.
• Monitor compliance with mandatory hospital training requirements.

Clinical Practice and Patient-Centered Care

• Ensure evidence-based nursing care is provided.
• Promote respect for patient rights, dignity, privacy, confidentiality, and informed participation.
• Ensure appropriate nursing assessment, care planning, implementation, evaluation, and documentation.
• Promote effective communication and safe clinical handover.
• Ensure timely escalation of deteriorating patients.
• Promote multidisciplinary collaboration.
• Monitor patient and family satisfaction with nursing services.

Risk Management and Incident Management

1. Identify nursing-related clinical and operational risks.

2. Ensure timely reporting and escalation of incidents.

3. Participate in root-cause analysis and other incident-review processes.

4. Implement corrective and preventive actions.

5. Monitor recurring incidents and develop strategies to prevent recurrence.

6. Ensure lessons learned from incidents are communicated to nursing staff.

J. Staffing and Resource Management

1. Develop nursing staffing plans according to patient volume, acuity, and service

requirements.

2. Ensure appropriate nurse-to-patient allocation.

3. Monitor overtime, absenteeism, turnover, and staffing shortages.

4. Participate in recruitment and selection of nursing personnel.

5. Recommend staffing adjustments based on service needs.

6. Ensure effective use and maintenance of nursing equipment and supplies.

7. Collaborate with Finance, HR, Procurement, and other departments regarding nursing resource requirements.

K. Documentation and Reporting

1. Ensure accurate, complete, timely, and confidential nursing documentation.

2. Review nursing reports and clinical records.

3. Submit regular nursing performance reports to hospital management.

4. Maintain accreditation and PSFHF-related nursing evidence.

5. Ensure nursing records are available and organized for internal and external assessment.

6. Ensure nursing data are used for quality improvement and management decisions.

7. Scope of Authority

The CNO has authority to:

 Direct and supervise nursing services.

 Assign and reassign nursing personnel according to service needs.

 Recommend recruitment, promotion, disciplinary action, and termination in accordance

with hospital policy.

 Stop or escalate unsafe nursing practices.

 Require corrective action for nursing non-compliance.

 Recommend changes to nursing policies, staffing, resources, and workflows.

 Initiate nursing quality-improvement activities.

 Escalate serious patient-safety and accreditation risks to executive management.

8. Decision-Making Authority

The CNO may make operational decisions within the approved nursing structure and hospital policies and shall escalate decisions involving significant financial, legal, clinical, staffing, or patient-safety risks to the appropriate executive authority.

9. Key Performance Indicators (KPIs)

The CNO shall be evaluated using measurable indicators including:

1. Nursing compliance with PSFHF requirements.

2. Nursing accreditation compliance rate.

3. Completion rate of nursing corrective-action plans.

4. Nursing documentation compliance.

5. Medication-administration error rate.

6. Patient falls rate.

7. Pressure injury rate.

8. Nursing-related adverse-event rate.

9. Patient satisfaction with nursing services.

10. Nursing staff turnover rate.

11. Nursing absenteeism rate.

12. Staff competency-assessment completion rate.

13. Mandatory training completion rate.

14. Infection-prevention compliance.

15. Hand-hygiene compliance.

16. Nursing audit completion rate.

17. Nursing management-round completion rate.

18. Timeliness of incident reporting and follow-up.

19. Compliance with professional licensing requirements.

20. Improvement in nursing-sensitive patient outcomes.

10. Required Training

The CNO should have training/competency in:

 WHO Patient Safety Friendly Hospital Framework (PSFHF)

 Patient safety

 Hospital accreditation standards

 Quality improvement

 Clinical governance

 Risk management

 Infection prevention and control

 Incident reporting and investigation

 Root-cause analysis

 Nursing leadership and management

 Clinical audit

 Patient rights and ethics

 Emergency preparedness

 Occupational health and safety

 Leadership and communication

 Healthcare data management and quality indicators

11. Required Skills

 Strategic nursing leadership

 Clinical leadership

 Patient-safety management

 Accreditation-readiness management

 Quality-improvement skills

 Clinical audit skills

 Risk assessment and management

 Problem-solving and decision-making

 Staff supervision and performance management

 Conflict resolution

 Communication and interpersonal skills

 Data analysis and report writing

 Training and mentoring

 Team-building and multidisciplinary collaboration

 Policy and SOP development

12. Working Relationships

The CNO shall work closely with:

 CEO

 DCEO

 CMO

 COO

 Quality and Safety Department

 HR Department

 IPC Department

 Medical Staff

 Pharmacy

 Laboratory

 Facility and Engineering

 Finance

 Procurement

 Hospital Administration

 Education Department

 Patients and families

 External regulatory and accreditation bodies